Preapproval and precertification
Preapproval and precertification requirements and member cost-sharing
Certain services require preapproval/precertification from AmeriHealth prior to being performed. This includes certain injectable and infusion specialty drugs that are administered by providers and eligible for coverage under the medical benefit.
For services or drugs that require preapproval/precertification, please call 1-800-275-2583. Providers registered with the Provider Engagement, Analytics & Reporting (PEAR) portal may submit requests electronically for services to be rendered at an acute care facility or ambulatory surgical center or office setting.
The Utilization Management department will evaluate your request and will notify your office once a decision has been reached for those cases that require clinical review. You will be provided with a preapproval/precertification reference number based on the determination of your request. Failure to complete required preapproval/precertification may result in a reduction in payment or nonpayment for the services not preapproved/precertified.
Providers and members may appeal our decision or provide additional information to support the request at any time during the evaluation process. Please refer to the Utilization Management section of the Provider Manual for Participating Professional Providers for more information.
Services that require preauthorization
- 2024 Precertification List (as of 1/1/2024)
- 2024 Precertification List with Carelon Opt Out (as of 1/1/2024)
- 2023 Precertification List (as of 7/1/2023)
- 2023 Precertification List with Carelon Opt Out (as of 7/1/2023)
Drug cost-sharing for commercial members
Members who are enrolled in Commercial FLEX products and certain customized plans are subject to applicable cost-sharing for select specialty injectable drugs. The list of these drugs is provided below.
- Specialty Drugs with Cost-Sharing (effective 1/1/2024)
- Specialty Drugs with Cost-Sharing (effective 7/1/2023)
NOTE: This list is subject to change. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. Individual benefits should be verified. If you have questions about member cost-sharing, please contact Customer Service at 1-800-275-2583.